Basic Information
| Provider Information | |||||||||
| NPI: | 1801116744 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIESEL | ||||||||
| FirstName: | GEOFFREY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2089 | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430507289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004756112 | ||||||||
| FaxNumber: | 4238261286 | ||||||||
| Practice Location | |||||||||
| Address1: | 1320 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430551822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403484710 | ||||||||
| FaxNumber: | 4238261290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2010 | ||||||||
| LastUpdateDate: | 01/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 35.126904 | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0142342 | 05 | OH | MEDICAID |